Adding the principles of lifestyle medicine into a busy ED shift is daunting. I still find it challenging to decide when to bring it up and figure out who will be interested in listening. I finally learned to use the same approach that I take with my substance use disorder patients.
It is nearly impossible to know when patients are ready to make a change, but if I fail to offer them a chance today, they are extremely unlikely to change today. Invite everyone to change whether or not you think they are ready.
I have been surprised with patients' responsiveness to this approach when we otherwise do not find a clear etiology for their symptoms. This can be a simple tool to add to your reassurance conversations and give them something tangible to consider.
It can also be generalized to just about any lifestyle principle that needs to be addressed, but we will drill down on nutrition prescriptions. The challenge obviously is that we are not going to be following up with these patients, so stress that they should discuss these plans with their primary care physicians.
Writing lifestyle prescriptions is a core competency in lifestyle medicine. (JAMA. 2010;304:202; https://bit.ly/3dTqIqQ.) They should follow a focused approach and be specific. Using the mnemonic SMARTEST is a great place to start. (Am J Lifestyle Med. 2020;14:271; https://bit.ly/3wr5ozs.)
As an emergency physician, however, I need a much shorter acronym. The American College of Lifestyle Medicine recommends that nutrition prescriptions (still undergoing validity testing) take the form of TAF:
T: Type of food (the more specific, the better)
A: Amount of food
Important concepts to consider and remember include:
- Nutrition recommendations should focus on a predominantly whole-food, plant-based diet encouraging less meat and dairy.
- Positive prescriptions are better than negative ones. Patient compliance increases when you ask them to add something to their lifestyle rather than asking them to take something away.
- Start slow, and remember less is more. Prescribing too many items at once can be overwhelming for patients. Make sure you get a sense of what the patient can handle.
- When writing nutrition prescriptions, consider medications that can be affected by certain foods, such as foods that are rich in vitamin K lowering warfarin levels and foods that inhibit cytochrome P450 like grapefruit increasing antidysrhythmic levels (and other drug classes like statins). (J Lifestyle Med. 2017;7:1; https://bit.ly/2SUNffA.)
- Recommending an increase in the intake of foods with high-volume, high-nutrient density but low-caloric density can make a huge impact on weight, digestion, and overall health, especially for chronic diseases. In other words, recommend vegetables that are rich in color as much as you can.
- When prescribing antibiotics, consider prescribing prebiotic foods that increase gut health in addition to prescribing probiotic pills and foods, such as those high in fiber (legumes and grains). Probiotic foods are those enriched with live cultures, like most yogurts (including plant-based yogurt alternatives). Tetracyclines and fluoroquinolones, however, can bind to calcium in the gut, so ingestion with foods with high calcium content like dairy can reduce absorption. (J Lifestyle Med. 2017;7:1; https://bit.ly/2SUNffA.) Alternatively, they can eat a plant-based yogurt alternative a couple of hours after the antibiotic.
- Americans are highly deficient in fiber and rarely meet the current USDA recommendations. (Am J Lifestyle Med. 2016;11:80; https://bit.ly/3yHb3D7.) Encourage your patients, especially diabetics, to increase this important macronutrient. Taking certain medications such as digoxin with high-fiber foods can reduce absorption. If unsure, recommend that medications not be taken with fiber-rich food.
Start the Conversation
Nutrition prescriptions that can be used in the ED include:
- Add one serving of dark leafy greens (spinach or kale) to your diet daily for the next 30 days. Please speak with your primary care doctor about whether you feel that this made an impact and discuss a plan moving forward. (Do not give this to patients taking warfarin.)
- Add one serving of legumes (beans, lentils, chickpeas) to your diet daily for the next 30 days. They are rich in fiber and an easy way to increase your daily fiber intake. If you have diabetes, monitor your blood glucose closely because increasing fiber can lower your blood sugar, which may require an adjustment to your medications.
- Add one apple to your diet daily for the next 30 days. They are rich in fiber and an easy way to increase your daily fiber intake. Please discuss this dietary change and how it has made you feel with your primary care doctor. If you are diabetic, please monitor your sugar closely.
Starting nutrition discussions in the emergency department can seem unnatural, but hopefully these tools break down some of those barriers and start the conversation. As emergency physicians, when we reassure patients, it is our hope that we have pointed the patient toward the right next steps. We think we understand our impact, but what we start in the ED extends far beyond the hospital walls. Let's make nutrition a part of that! As Hippocrates said, “Let food be thy medicine, and medicine thy food.”
Learn more about lifestyle medicine from the American College of Lifestyle Medicine at https://lifestylemedicine.org. Find more information about nutrition prescriptions and more practical tools on prescribing nutrition interventions in the ACLM course, “Food as Medicine,” at https://bit.ly/3hsEiU8.
Dr. Harrisonis board-certified in emergency medicine and lifestyle medicine, and practices emergency medicine at Bridgeport Hospital-Yale New Haven Health. Learn more about the intersection of emergency medicine and lifestyle medicine by visiting her website atwww.acute2root.com. Find more information on the American College of Lifestyle Medicine athttps://www.lifestylemedicine.org. Follow her on Twitter@acute2root.